Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Papers
  • Published:

Reducing the burden of sexually transmitted infections in resource-limited settings: the role of improved diagnostics

There is a great need for improved diagnosis of curable bacterial sexually transmitted infections among women in developing countries. We found that wider access to new diagnostic tests has a greater overall impact on health outcomes than improvements in test sensitivity or specificity.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Prices vary by article type

from$1.95

to$39.95

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Antenatal syphilis decision trees.
Figure 2: Decision trees for gonorrhoea and chlamydia.
Figure 3
Figure 4: Impact of a 10% change in a given input parameter on adjusted lives saved for two different hypothetical antenatal syphilis screening tests compared with the status quo laboratory-based rapid plasma reagin (RPR) test.
Figure 5: Impact of a 10% change in a given input parameter on adjusted disability-adjusted life years (DALYs) saved for two different hypothetical gonorrhoea and chlamydia diagnostic tests compared with the status quo diagnostic strategies.
Figure 6

References

  1. World Health Organization. Global Prevalence and Incidence of Selected Curable Sexually Transmitted Infections: Overview and Estimates (WHO, Geneva, 2001).

  2. World Health Organization. Projections of Mortality and Burden of Disease to 2030 (WHO, Geneva, 2005).

  3. World Health Organization Regional Office for South-East Asia. Guidelines for Sexually Transmitted Infections: Prevalence Study. Report No. SEA-STD-41 (WHO, Geneva, 2001).

  4. Mehmet, G. & Ledger, W. J. Syphilis in pregnancy. Sex Transm. Infect. 76, 73–79 (2000).

    Article  Google Scholar 

  5. Peeling, R. W. & Ye, H. Diagnostic tools for preventing and managing maternal and congenital syphilis: an overview. Bull. World Health Organ. 82, 439–446 (2004).

    PubMed  PubMed Central  Google Scholar 

  6. Chesson, H. W. & Pinkerton, S. D. Sexually transmitted diseases and the increased risk for HIV transmission: implications for cost-effectiveness analyses of sexually transmitted disease prevention interventions. J. Acquir. Immune Defic. Syndr. 24, 48–56 (2000).

    Article  CAS  PubMed  Google Scholar 

  7. Cohen, M. S. et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1. Lancet 349, 1868–1873 (1997).

    Article  CAS  PubMed  Google Scholar 

  8. Fleming, D. T. & Wasserheit, J. N. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm. Infect. 75, 3–17 (1999).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Laga, M. et al. Non-ulcerative sexually transmitted diseases as risk factors for HIV-1 transmission in women: results from a cohort study. AIDS 7, 93–102 (1993).

    Article  Google Scholar 

  10. Quinn, T. C. Association of sexually transmitted diseases and infection with the human immunodeficiency virus: biological cofactors and markers of behavior interventions. Int. J. STD AIDS 7, 17–24 (1996).

    Article  PubMed  Google Scholar 

  11. Vuylsteke, B. et al. Clinical algorithms for the screening of women for gonococcal and chlamydial infection: evaluation of pregnant women and prostitutes in Zaire. Clin. Infect. Dis. 17, 82–88 (1993).

    Article  CAS  PubMed  Google Scholar 

  12. World Health Organization. Draft Global Strategy for the Prevention and Control of Sexually Transmitted Infections 2005–2010: Breaking the Chain of Transmission. WHO/RHR/05.16 (WHO, Geneva, 2005).

  13. Dallabetta, G. A. & Gerbase, A. C. Problems, solutions, and challenges in syndromic management of sexually transmitted diseases. Sex. Transm. Infect. 74, S1–S11 (1998).

    PubMed  Google Scholar 

  14. Dallabetta, G. A., Laga, M. & Lamptey, P. L. in Control of Sexually Transmitted Diseases: A Handbook for the Design and Management of Programs (AIDSCAP/Family Health International, Arlington, Virginia, 1996).

    Google Scholar 

  15. Harrison, A. et al. Syndrome packets and health worker training improve sexually transmitted disease case management in rural South Africa: randomized controlled trial. AIDS 14, 2769–2779 (2000).

    Article  CAS  PubMed  Google Scholar 

  16. Moherdaui, F. et al. Validation of national algorithms for the diagnosis of sexually transmitted diseases in Brazil: results from a multicentre study. Sex. Transm. Infect. 74 (suppl. 1), S38–S43 (1998).

    PubMed  Google Scholar 

  17. Rottingen, J. A., Cameron, D. W. & Garnett, G. P. A systematic review of the epidemiologic interactions between classic sexually transmitted diseases and HIV: how much really is known? Sex. Transm. Dis. 28, 579–597 (2001).

    Article  CAS  PubMed  Google Scholar 

  18. Gloyd, S., Chai, S. & Mercer, M. A. Antenatal syphilis in sub-Saharan Africa: missed opportunities for mortality reduction. Health Policy Plan. 16, 29–34 (2001).

    Article  CAS  PubMed  Google Scholar 

  19. Young, H. Guidelines for serological testing for syphilis. Sex. Transm. Infect. 76, 403–405 (2000).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Hook, E. W. I. & Peeling, R. W. Syphilis control a continuing challenge. N. Engl. J. Med. 351, 122–124 (2004).

    Article  CAS  PubMed  Google Scholar 

  21. Scholes, D. et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. N. Engl. J. Med. 334, 1362–1366 (1996).

    Article  CAS  PubMed  Google Scholar 

  22. Vickerman, P., Watts, C., Alary, M., Mabey, D. & Peeling, R. W. Sensitivity requirements for the point of care diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in women. Sex. Transm. Infect. 79, 363–367 (2003).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Hook, E. W. & Handsfield, H. H. in Sexually Transmitted Diseases (eds Holmes, K.K. et al.) 451–466 (McGraw-Hill, Health Professions Division, New York, 1999).

    Google Scholar 

  24. World Health Organization. Laboratory Tests for the Detection of Reproductive Tract Infections (WHO, Geneva, 1999).

  25. World Health Organization. Guidelines for the Management of Sexually Transmitted Infections (WHO, Geneva, 2003).

  26. Koumans, E. H., Johnson, R. E., Knapp, J. S. & St. Louis, M. E. Laboratory testing for Neisseria gonorrhoeae by recently introduced nonculture tests: a performance review with clinical and public health considerations. Clin. Infect. Dis. 27, 1171–1180 (1998).

    Article  CAS  PubMed  Google Scholar 

  27. Gift, T. L., Pate, M. S., Hook, E. W. & Kassler, W. J. The rapid test paradox: when fewer cases detected lead to more cases treated: a decision analysis of tests for Chlamydia trachomatis . Sex. Transm. Dis. 26, 232–240 (1999).

    Article  CAS  PubMed  Google Scholar 

  28. Peeling, R. W. in Program and Abstracts of the 45th Interscience Conference of Antimicrobial Agents and Chemotherapy. Abstract 1333 (American Society for Microbiology, Washington DC, 2005).

    Google Scholar 

  29. Haberland, N., Winikoff, B., Sloan, N., Coggins, C. & Elias, C. Case Finding and Case Management of Chlamydia and Gonorrhea Infections among Women: What we Do and Do Not Know. (The Population Council, Inc., New York, 1999).

    Google Scholar 

  30. Girosi, F. et al. Developing and interpreting models to improve diagnostics in developing countries. Nature S1, 3–8 (2006).

    Article  Google Scholar 

  31. Aledort, J. E., Rafael, M. E. & Shea, M. A Technical Report: Reducing the Burden of Sexually Transmitted Infections and HIV/AIDS in Resource Poor Countries: the Role of Improved Diagnostics for Gonorrhoea and Chlamydia. WR-415-HLTH (RAND Corporation, Santa Monica, 2006).

    Google Scholar 

  32. Aledort, J. E., Shea, M. & Girosi, F. A Technical Report: Estimating the Health Impact of New Antenatal Syphilis Screening Diagnostics in Africa. WR-416-HLTH (RAND Corporation, Santa Monica, 2006).

    Google Scholar 

  33. Terris-Prestholt, F. et al. Is antenatal syphilis screening still cost effective in sub-Saharan Africa. Sex. Transm. Infect. 79, 375–381 (2003).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Watson-Jones, D. et al. Syphilis in pregnancy in Tanzania. I. Impact of maternal syphilis on outcome of pregnancy. J. Infect. Dis. 186, 940–947 (2002).

    Article  PubMed  Google Scholar 

  35. Alary, M. et al. Decline in the prevalence of HIV and sexually transmitted diseases among female sex workers in Cotonou, Benin, 1993–1999. AIDS 16, 463–470 (2002).

    Article  PubMed  Google Scholar 

  36. Deceuninck, G. et al. Improvement of clinical algorithms for the diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis by the use of Gram-stained smears among female sex workers in Accra, Ghana. Sex. Transm. Dis. 27, 401–410 (2000).

    Article  CAS  PubMed  Google Scholar 

  37. Diallo, M. O. et al. Evaluation of simple diagnostic algorithms for Neisseria gonorrhoeae and Chlamydia trachomatis cervical infections in female sex workers in Abidjan, Cote d'Ivoire. Sex. Transm. Infect. 74 (suppl. 1), S106–S101 (1998).

    PubMed  Google Scholar 

  38. Germain, M. et al. Evaluation of a screening algorithm for the diagnosis of genital infections with Neisseria gonorrhoeae and Chlamydia trachomatis among female sexworkers in Benin. Sex. Transm. Dis. 24, 109–115 (1997).

    Article  CAS  PubMed  Google Scholar 

  39. Kilmarx, P. H. et al. in XI International Conference on AIDS (Vancouver, British Columbia, 1996).

    Google Scholar 

  40. Ndoye, I. et al. Diagnosis of sexually transmitted infections in female prostitutes in Dakar, Senegal. Sex. Transm. Infect. 74 (suppl. 1), S112–S117 (1998).

    PubMed  Google Scholar 

  41. Nessa, K. et al. Sexually transmitted infections among brothel-based sex workers in Bangladesh: high prevalence of asymptomatic infection. Sex. Transm. Dis. 32, 13–19 (2005).

    Article  PubMed  Google Scholar 

  42. Vuylsteke, B. et al. High prevalence of sexually transmitted diseases in a rural area in Mozambique. Genitourin. Med. 69, 427–430 (1993).

    CAS  PubMed  PubMed Central  Google Scholar 

  43. Vandepitte, J. et al. Estimates of the number of female sex workers in different regions of the world. Sex. Transm. Infect. s82, iii18–iii25 (2006).

    Google Scholar 

  44. Murray, C. & Lopez, A. (eds) The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected to 2020 (Harvard Univ. Press on behalf of the WHO and the World Bank, Cambridge, 1996).

    Google Scholar 

  45. Vickerman, P. et al. Are targeted HIV prevention activities still cost-effective in high prevalence settings? Results from an STI treatment intervention for sex-workers in Hillbrow, South Africa. Sex. Transm. Dis. 33, S122–S132 (2006).

    Article  PubMed  Google Scholar 

  46. Vickerman, P., Watts, C., Peeling, R. W., Mabey, D. & Alary, M. Modeling the cost-effectiveness of rapid point-of-care diagnostic tests for the control of HIV and other sexually transmitted infections amongst female sex workers. Sex. Transm. Infect. 82, 403–412 (2006).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Manning, W., Fryback, D. & Weinstein, M. in Cost Effectiveness in Health and Medicine (eds Gold, M., Siegel, J., Russell, L. & Weinstein, M.) 247–275 (Oxford Univ. Press, New York, 1996).

    Google Scholar 

  48. Hayes, R. J., Schulz, K. F. & Plummer, F. A. The cofactor effect of genital ulcers on the per-exposure risk of HIV transmission in sub-Saharan Africa. J. Trop. Med. Hyg. 98, 1–8 (1995).

    CAS  PubMed  Google Scholar 

  49. Fitzgerald, D. W., Behets, F. M., Lucet, C. & Roberfroid, D. Prevalence, burden, and control of syphilis in Haiti's rural Artibonite region. Int. J. Infect. Dis. 2, 127–131 (1998).

    Article  CAS  PubMed  Google Scholar 

  50. Watson-Jones, D. et al. Syphilis in pregnancy in Tanzania. II. The effectiveness of antenatal syphilis screening and single-dose benzathine penicillin treatment for the prevention of adverse pregnancy outcomes. J. Infect. Dis. 186, 948–957 (2002).

    Article  CAS  PubMed  Google Scholar 

  51. Finelli, L., Berman, S. M., Koumans, E. H. & Levine, W. C. Congenital syphilis. Bull. World Health Organ. 76 (suppl. 2), 126–128 (1998).

    PubMed  PubMed Central  Google Scholar 

  52. Bollen, L. J. M. et al. in 16th Biennial Meeting of the International Society for STD Research (Amsterdam, The Netherlands, 2005).

    Google Scholar 

  53. Gerbase, A. C., Rowley, J. T. & Mertens, T. E. Global epidemiology of sexually transmitted diseases. Lancet 351 (suppl. 3), 2–4 (1998).

    Article  PubMed  Google Scholar 

  54. Mayaud, P. et al. Risk assessment and other screening options for gonorrhoea and chlamydial infections in women attending rural Tanzanian antenatal clinics. Bull. World Health Organ. 73, 621–630 (1995).

    CAS  PubMed  PubMed Central  Google Scholar 

  55. Mayaud, P. et al. Validation of a WHO algorithm with risk assessment for the clinical management of vaginal discharge in Mwanza, Tanzania. Sex. Transm. Infect. 74 (suppl. 1), S77–S84 (1998).

    PubMed  Google Scholar 

  56. Pettifor, A., Walsh, J., Wilkins, V. & Raghunathan, P. How effective is syndromic management of STDs? A review of current studies. Sex. Transm. Dis. 27, 371–385 (2000).

    Article  CAS  PubMed  Google Scholar 

  57. Vuylsteke, B. L. et al. Assessment of the validity of and adherence to sexually transmitted infection algorithms at a female sex worker clinic in Abidjan, Cote d'Ivoire. Sex. Transm. Dis. 30, 284–291 (2003).

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank B. Schackman (Weill Medical College of Cornell University, New York, USA) and G. Garnett (Imperial College London, UK) for helpful comments on earlier drafts. In addition, we thank F. Terris-Prestholt (London School of Hygiene and Tropical Medicine, UK) and P. Mwaba (University of Zambia, School of Medicine, Lusaka Zambia) for contributions to the analysis and K. Leuschner (RAND Corporation, Santa Monica, California, USA) for assistance in drafting the manuscript.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Julia E. Aledort.

Additional information

This article has not been written or reviewed by the Nature editorial team and Nature takes no responsibility for the accuracy or otherwise of the information provided.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Aledort, J., Ronald, A., Rafael, M. et al. Reducing the burden of sexually transmitted infections in resource-limited settings: the role of improved diagnostics. Nature 444 (Suppl 1), 59–72 (2006). https://doi.org/10.1038/nature05447

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nature05447

This article is cited by

Comments

By submitting a comment you agree to abide by our Terms and Community Guidelines. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate.

Search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing